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Burnett County Office of Zoning Administrator W � o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT v 3. <br /> o Ap <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m c <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 0- <br /> Roi ......1�`I�.Sar✓............. ............................................................................................ o <br /> OWN R lease rint) CONTRACTOR or SURVEYOR or AGENT <br /> . ... .... i <br /> ............... <br /> ADDRESS ADDRESS : <br /> .......................................................................... .......................................................................... <br /> ADDRESS ADDRESS 1 :A <br /> �►� <br /> ............................................................................... ........... . .......................................................................................... <br /> PHON PHONE <br /> ....... ..... ............... <br /> ........................................... <br /> PLU Btj <br /> WELL DRILLER <br /> .............. <br /> ADDRESS ADDRESS :off o <br /> ._«• < <br /> . . . ................................................................................... . .. ............................................ ....................................... j ,.: <br /> PHONE P..HONE.. Z H r <br /> DESCRIPTION 4. SanitaryFacilities: r �O o ° <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> New Building Type of Cons U) <br /> No. Bedrooms <br /> Addition ,. �l!!r(,1Qt// . ... Septic Tank Size Gals. rJt. !p <br /> . . .. <br /> Sanitary .. it <br /> Size ..Z.. ... ft. x .�••• ft. <br /> Filling <br /> .......... Height............. Stories ............... 4a. Absorption Fiel S'te: <br /> Moving Area Soil Type ....... .. �� o <br /> ......................................... <br /> . .................... <br /> Grading Slope ..........Jr .p...................... <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ......�..................... <br /> Privy home,garagg,motel, tc.) Dry Well .......... <br /> Well �y, Q/ry� Seepage Trench 01... ... j!'/�. ... . Privy ...... <br /> ..... W iW E <br /> — Subdivision .......... ��k3S""' <br /> Seepage Bed dt.... <br /> --------------------------------------------------- �r�---= C <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc.,should be sketched in Fig. A. Include road a <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- I <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> N is <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: All! Fig. A. m <br /> ................ ft.x .............. ft.— rJJ... ...........K............ s .ft. <br /> yolk X 10m <br /> > o' �PT1C rAIVIc °' <br /> h9f <br /> o <br /> Ih-y9�A • l�ous� �ox/c�c�7E N <br /> �N X 36 � - - 1`0 <br /> O <br /> WE�� W <br /> — — - -I I 1�vr�l�� �1 . <br /> � �� iso o <br /> r <br /> pRiUE srEP��C 61-50 <br /> /27 eX 3s' y10 <br /> t)r -o::E� <br /> m <br /> 'aQ tn�y l !D <br /> Z O O <br /> o <br /> v> -� <br /> J N <br /> p . 7t1 <br /> SGT m <br /> Q <br /> y� �9 /...... s € c <br /> Signature of Owner or Agent Date T x i m <br /> Remarks ............................................................................................................................................................................ <br /> to <br /> ........................................................................................................................................................................................... :1A1 <br /> o. <br /> Inspection Date ....................................... .............. o b <br /> Colo m <br /> �✓:•. ................... : 0 Colo m <br /> Zoning Administrator o 0 0 0 o CA <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build <br /> Ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> with is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />